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Scott Weingart. Do Patients with COPD Exac need a PE Workup?. EMCrit Blog. Published on May 28, 2015. Accessed on January 21st 2019. Available at [http://emcrit.org/emcrit/do-patients-with-copd-exac-need-a-pe-workup/ ].

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caseyparker207

Hey Scott Are your trying to pick a Twitter fight! PE seems to inflame the masses! N = 49 – so not really enough data to make conclusions about much. Definitely too small to be a “game changer” for such an important question. The presence of a PE or ‘pee wee E’ on a 64slice CT is not a meaningful clinical outcome. Much of those could well be “lung lint” – i.e. clot that the lung has successfully filtered out of old folks blood! A better outcome would be death by PE (need 1000s of pts for that) or at least some measure of chronic respiratory incapacity after a PE is diagnosed. e.g. exercise tolerance, 6-minute walk, pulmonary HT or oxygen requirements etc Q: “If a PE lodges in your pulmonary vasculature and it doesn’t make you short-winded, does it make a sound?” Interesting that they did not use US to look for leg clots – as the postulate is that COPD is an acute, inflammatory, prothrombotic state – so these wheezers area t risk of VTE… and if you want to find clots – why not look in BOTH the legs and the lungs to show it happens? As… Read more »

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3 years ago

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Henry Arst, MD

pretty scary conclusion, knee jerk work up for every COPD exacerbation, I wonder if a preceding URI,change in sputum color or volume,etc would explain the etiology for the flare and thus this subgroup would be less likely to have a coexistent PE as a cause..let’s hope for a larger study in the future

My first thought was “n=49”? This changes no game (unless the other team has n=48?). What we really need to know is what characteristics of a COPD exacerbation, or pleural effusion, or asthma exacerbation… should cause us to do a PE workup.

Always love the PE discussion, “How should we work up PE?” We don’t workup PE, we workup chest pain, shortness of breath. Not PE. The PE workup is stupidly simple, get a CTA or VQ. The questions that are important are:
1. When do we pull the trigger to get those tests?
2. What do we do with the results? a la Victoria.

Agree with the above – not a game changer at all. In fact, it would be dangerous to change practice based on this tiny study. Given the clinicians diagnosed infective exacerbations of COPD, there is a real chance that many of these PE’s are incidental PE’s of questionable relevance. Given how little we know about the value of discovering incidental PE and any benefit of treating such PE’s v’s the harms of testing and anticoagulation, it would be very dangerous to advocate anything that resembles a “PE screening program” in certain populations. This is particularly of concern given there is data suggesting possible net harm from our current approach to patients being investigated for PE in general. Related to this, this study also raises the question of De-Novo PE (DNPE). The long held belief that PE’s are always emboli from distal veins and that their presence indicates a propensity for further such emboli to recur may not be true, particularly in certain conditions. PE may be in fact occurring de novo in the lung as a thrombus rather than embolus, particularly in conditions with increased lung inflammation. In a study by Van Gent et al 2014 [http://www.ncbi.nlm.nih.gov/pubmed/24747459], they looked at… Read more »

This study has a few serious issues with presentation that make its significance and generalizability hard to determine. First, it is missing the consort diagram, which is essential in a study of this nature. They give the impression (in fact, that state point blank) that it was a study of 49 consecutive patients with AECOPD. The reality is that is unlikely to be true. Any clinical trialist knows that enrollment is clinical trials is difficult, especially in an ED or ICU setting where things happen quickly. More likely is that 49 consecutive patients with UNEXPLAINED AECOPD were included. The distinction is very significant. There are previous studies documenting a similar rate of VTE in patients with unexplained AECOPD (for example, Tillie-Leblond et al Ann Intern Med. 2006). Even in this manuscript, the authors imply in one example that the patient in fact has unexplained AECOPD (Figure 1). What I take from the totality of the literature is that most patients with AECOPD have typical symptoms including increased cough and a change in sputum volume or color. In patients with AECOPD with increasing dyspnea but no significant change in cough or sputum, I strongly consider am alternative trigger for the exacerbation,… Read more »